This invention relates to a method of performing ophthalmological surgery, more specifically, to a method of performing a translacrimal laser dacryocystorhinostomy (DCR).
A substantial number of patients are seen by physicians, particularly ophthalmologists, each year complaining of symptoms indicating a blockage of the lacrimal drainage apparatus, i.e., the tear drainage system of the eye. These symptoms include excessive tears which can flow down the cheeks. Often the symptoms are caused when the volume of tears produced exceeds the normal drainage capacity of the lacrimal system. More commonly, this problem occurs when there is an obstruction in the tear drainage apparatus (obstructive epiphora). A large number of the patients have an anatomical obstruction in the membranous tear drainage passage or a functional defect therein.
Constantly watering eyes is an annoyance and an embarrassment and can cause impaired vision and excoriation of the skin on the cheeks and face. Also, obstructive passages can become infected resulting in contaminated tears which can pose a threat to the patient's vision.
Most patients with obstructive epiphora can be relieved by a surgical procedure wherein a mucosa-lined passageway to the nose is constructed to allow the drainage of the tears.
The most common surgical procedure used to correct the defect is a dacryocystorhinostomy (DCR). Traditional DCR surgery requires making an incision on the side of the nose, suturing the muscles to draw the muscles out of the way, removing sufficient bone from the nose to allow the surgeon to incorporate the lacrimal sac into the nose so that the tears can drain into the nasal passages.
There are several serious complications involved with lacrimal surgery. The most dangerous complication is hemorrhage. Ordinarily, primary hemorrhage is handled by the surgeon during the procedure and is not a long term problem. However, secondary hemorrhage can occur from four to seven days post-op and is usually associated with infection of the mucosa that involves adjacent blood vessels. This complication usually responds to antibiotics. Occasional stitch absesses can develop which also require treatment with antibiotics. Unsightly scars can result from traditional DCR surgery since the surgeon has to make an incision on the side of the nose.
Finally, there can still be a failure to achieve proper drainage despite surgery due to several reasons. First, the surgeon may have performed an inappropriate procedure, usually due to an error in diagnosis. Secondly, the technique of the surgeon may result in failure, due to inadequately marsupialization of the sac to the nose. Re-operation may be required if the surgery fails for any one of the aforestaed complications. Of course, re-operation has its similar attendant risks.
Recently Massaro has described a transnasal method to form a fistula track from the nose to the lacrimal sac using an Argon laser. However, the method has several drawbacks including poor visualization of the intra-nasal operative field as well as the potential for significant thermal drainage. The argon wavelength is not a very effective bone cutting device. It is therefore, an object of the present invention to provide a method of performing a lacrimal drainage operation using a laser and a video endoscope through the lacrimal system.
Another object of the present invention is to provide a method of performing lacrimal drainage operation does not require skin incision and the associated risk.
Still another object of the present invention is to provide a method of performing a lacrimal drainage operation wherein a laser is passed transcanalicularly to create a full thickness fistula from the lacrimal sac to the nose.
Yet another object of the present invention is to provide a method of performing a lacrimal drainage operation wherein a video endoscope is used to view the operative field.
A further objection of the present invention is to provide a method of performing lacrimal drainage operation using laser technology that is safe and effective, has a low incidence of untord complications and is well suited for its intended purposes. In particular, modified pulsed YAG laser (long pulse duration), Holmium, erbium, or other infrared lasers are better suited for bone cutting.
Another object of this claim is to use a transclacrimal laser to open the naturally occurring drainage route (the nasolarcrimal duct) by perforating any soft tissue or dacryolth obstruction. Another object of this claim is to provide a non-incisional means to revise a failed conventional DCR.
Briefly stated, a method of performing lacrimal drainage surgery is provided wherein a video endoscope is passed from one punctum and is canaliculus into the lacrimal sac. A bone cutting laser with accompanying fiber optic illumination is passed through the other punctum and its associated canaliculus. The laser is activated under direct visualization to create a full thickness fistula from the lacrimal sac into the interior of the nose. Videoendoscopy through the nose can be used to help place the fistual site, avoiding nasal structure or the turbinater. A temporary tube or stent can be passed through the fistula to prevent closure of the fistula.